Sedation

It sure as heck is NOT! Not in my corner of the world.

I agree with meanmaryjean, this is not common practice in my area either.

Did he provide a source, other than his belief, to support this? If this is indeed an "industry standard" it should be easy enough for him to do so.

He provided 2 sources but neither one supported his claim. I feel much better now to know that what I believed and read was correct

Absolutely not. Stable patients coming in for outpatient surgery will often have some nitrous oxide started before their IV start, but that is not for anyone but the most stable of kids and certainly not in the ED or PICU.

In the ED we use J-tips with buffered lidocaine, if I'm doing a USGPIV in the PICU and it is a difficult approach I will typical infiltrate a little lidocaine or 1% benadryl. If we have time before access we can apply EMLA.

Does he have limited experience starting pediatric IVs? I wonder if he gives the ketamine so that the kid isn't pulling or otherwise making his start more difficult.

that's hilarious. we don't even routinely give fentanyl while placing a PICC line in our neonates, just sucrose. We will give fentanyl if the baby is a squirmer : )

I've put lots of IVs in pediatric patient over the years, just usually ask the parents to leave the room and the kids are usually better (older kids.)

No way, that would be very dangerous and to much risk for such a minor procedure.

I work on an IV team and if the IV isn't needed emergently we apply EMLA cream to 2 or 3 potential sites and let it sit for about an hour, usually this would be a direct admit to pediatrics.

If the IV start is more urgent, or it just isn't conducive to wait an hour we just do it. In infants you can use sucrose to calm them down. I find talking to older kids is actually more effective than one would think. I tell them they can yell, scream, cry do whatever they want, except move!

Iv's do hurt of course, but as I said that would be absolutely crazy to sedate EVERY kid!!!

Annie

Ketamine is for some reason presumed to be a dangerous medication, such as proposing that ketamine is too dangerous and that they only use lidocaine, the problem with that is Lidocaine is far more dangerous than ketamine. I think the problem here is with a poor understanding of ketamine rather than a CRNA proposing a (not actually) dangerous intervention.

Ketamine is for some reason presumed to be a dangerous medication, such as proposing that ketamine is too dangerous and that they only use lidocaine, the problem with that is Lidocaine is far more dangerous than ketamine. I think the problem here is with a poor understanding of ketamine rather than a CRNA proposing a (not actually) dangerous intervention.

Are you seriously suggesting that 3-5 mg/kg of IM ketamine has less risk than 0.25 mL of ID buffered lidocaine or 2-3 mL of EMLA?

I just don't see why giving sedation should be "routine," without at least trying without it. Less medications (and risk for adverse reactions) the better.

Are you seriously suggesting that 3-5 mg/kg of IM ketamine has less risk than 0.25 mL of ID buffered lidocaine or 2-3 mL of EMLA?

I'm not suggesting it, ketamine is quantitatively less dangerous than lidocaine at any common dose and by any systemic route, the main risk of lidocaine even when given ID is that there is variable absorption by the ID route and the risks of quicker absorption include cardiac arrest. That doesn't mean lidocaine shouldn't be used for this purpose, the risks are relatively small, but the risks of ketamine are even smaller.

I'm curious what people believe the overwhelming risk of ketamine to be?

I'm not suggesting it, ketamine is quantitatively less dangerous than lidocaine at any common dose and by any systemic route, the main risk of lidocaine even when given ID is that there is variable absorption by the ID route and the risks of quicker absorption include cardiac arrest. That doesn't mean lidocaine shouldn't be used for this purpose, the risks are relatively small, but the risks of ketamine are even smaller.

I'm curious what people believe the overwhelming risk of ketamine to be?

2.5 mg of ID or 10 mg of local lido is not going to have a profound systemic effect on a patient if it is being administered by a competent clinician; if said person is not aspirating a syringe and directly injecting large doses that is not a matter of medication safety but rather clinical competency. The extracellular matrix around capillary tissues will only allow for a certain rate of absorption, there is no magical spot where this matrix is thinner or non-existant.

Ketamine is a dissociate hypnotic and prevents patients from consciously being able to protect their own airway. Think of it in the same way as bipap on a profoundly hypercapnic patient. The patient may still have a cough and gag reflex but if they vomit they are not going to sit up and put their head over the side of the rails. Further ketamine can have respiratory depression in some patients, especially in small children or those who have been treated with other narcotics or benzos. I have taken care of multiple kids who have been transferred in from outside hospitals and freestanding EDs who either through poor administration or individual reaction ended up requiring PICU admission because of profound respiratory depression including one kid who ended up needing to be intubated for two days after a single dose of ketamine (we never had to give additional sedation during his stay).

Ketamine certainly has risks and should never be treated as a benign medication. This is in many ways the new chloral hydrate, its the new magical drug for sedation with the rumor of magical properties which in reality are not true.